11/16/2019 Examples Of Public Health Programs
SUMMARY OF CHAPTER RECOMMENDATIONS The six major government health care programs—Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program—provide health care services to about one-third of Americans. The federal government has a responsibility to ensure that the more than $500 billion invested annually in these programs is used wisely to reduce the burden of illness, injury, and disability and to improve the health and functioning of the population. It is imperative that the federal government exercise strong leadership in addressing serious shortcomings in the safety and quality of health care in the United States. The six major government health care programs serve older persons, persons with disabilities, low-income mothers and children, veterans, active-duty military personnel and their dependents, and Native Americans. Three of these programs—Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP)—were devised for groups for whom the health care market has historically failed to work because of their high health care needs and low socioeconomic status. The remaining three programs—DOD TRICARE, VHA, and IHS—serve particular populations with whom the federal government has a special relationship, respectively, military personnel and their dependents, veterans, and Native Americans. Many millions of Americans receive services through multiple government programs simultaneously.
Low-income Medicare beneficiaries who qualify for both Medicare and Medicaid account for 17 percent of the Medicare population and 19 percent of the Medicaid population (Gluck and Hanson, 2001; Health Care Financing Administration, 2000). These “dual eligibles” account for a total of 28 percent of Medicare expenditures and 35 percent of Medicaid expenditures. Native Americans eligible to receive services through IHS may also qualify for Medicaid if they satisfy income and other eligibility requirements, and those aged 65 and older may qualify for Medicare.
Nearly 45 percent of veterans are 65 years and older and also qualify for Medicare (Van Diepen, 2001b). In addition, many Americans eligible for these programs have private supplemental insurance as well. Thus, patients and clinicians would surely benefit from greater consistency in quality enhancement requirements, measures, and processes across public and private insurance programs. Provides a capsule summary of the six government health care programs. A more detailed description of the programs is provided in the following section.
The broad trends affecting the needs and expectations of the programs’ beneficiaries are then reviewed. The final section examines some key features of the programs beyond their quality enhancement processes. FIGURE 2-1 Medicare beneficiaries with cognitive and/or physical limitations as a percentage of beneficiary population and total Medicare expenditures, 1997. NOTE: A person with cognitive impairment has difficulty using the telephone or paying bills, or has Alzheimer’s disease, mental retardation, or various other mental disorders. A person with physical impairment is someone reporting difficulty performing three or more activities of daily living.
SOURCE: Reprinted with permission from Moon and Storeygard, 2001. Penditure Panel Survey, 1998). The fastest-growing sectors in Medicare in terms of spending (though not the largest proportion of total program spending) have been home health, skilled nursing facilities, and hospice care, reflecting a shift in demand toward more chronic care. MEDICAID Medicaid serves about 42 million people who are poor and who require health care services to achieve healthy growth and development goals or meet special health care needs. The program covers low-income people who meet its eligibility criteria, such as children, pregnant women, certain low-income parents, disabled adults, federal Supplemental Security Income (SSI) recipients (low-income children and adults with severe disability), and the medically needy (non-poor individuals with extraordinary medical expenditures who meet spend-down requirements generally for long-term care).
There is a good deal of variability across states in the maximum income for eligibility. FIGURE 2-2 Medicare beneficiaries with five or more chronic conditions account for two-thirds of Medicare spending. SOURCE: Centers for Medicare and Medicaid Services, 1999.
Medicaid is administered and financed jointly by the federal government and the states, although the federal government pays for over 50 percent of aggregate program expenditures (U.S. Government Printing Office, 2002). There is a good deal of variability in methods of health care delivery and financing across states. Medicaid programs rely extensively on private-sector health care providers, managed care plans, and community health centers to deliver services and, to a lesser degree, state, county, or other publicly owned facilities or programs. Nationwide, over half of the total Medicaid population is enrolled in Medicaid managed care arrangements.
Institutionalized, disabled, dually eligible, and elderly beneficiaries are most likely to receive services through FFS payment arrangements. The majority of Medicaid beneficiaries are children (54 percent), most under the age of 6 (see ). Each year, over one-third of all births in the United States are covered by Medicaid.
While a minority of the program in terms of population (26 percent), the aged/blind/disabled account for 71 percent of program expenditures. Over half of Medicaid expenditures are for long-term care services, with the majority going to institutional long-term care providers (Centers for Medicare and Medicaid Services, 2000a). While coordinated collection of Medicaid data from the states is lacking, other data sources indicate a substantial prevalence of chronic condi.
FIGURE 2-3 Distribution of persons served through Medicaid and payments by basis of eligibility, fiscal year 1998. NOTE: Disabled children are included in the aged, blind and disabled category.
SOURCE: Centers for Medicare and Medicaid Services, 2000a. Tions in the program. These conditions include asthma, diabetes, neurological disorders, high blood pressure, mental illness, substance abuse, and HIV/AIDS (Centers for Medicare and Medicaid Services, 2001c; Medical Expenditure Panel Survey, 1996; Westmoreland, 1999).
Health
STATE CHILDREN’S HEALTH INSURANCE PROGRAM Designed as a joint federal-state program, SCHIP was created in 1997 to provide health insurance to poor and near-poor children through age 18 without another source of insurance. Approximately 4.6 million children were enrolled in SCHIP as of fiscal year 2001 (Centers for Medicare and Medicaid Services, 2000b). SCHIP is targeted to children with incomes that exceed Medicaid eligibility requirements but remain under 200 percent of the federal poverty level (FPL) (Rosenbach et al., 2001). Have expanded SCHIP to children with family incomes up to 300 percent of FPL (Rosenbaum and Smith, 2001). SCHIP operates as a block grant program to the states. States have the option of creating SCHIP programs as Medicaid expansions, as separate programs, or as combined programs (i.e., Medicaid expansions for some income levels and separate programs for higher income levels).
The SCHIP program has been implemented slowly and variably across states. Most states rely on managed care arrangements as their primary mechanism of service delivery for both healthy children and those with special health care needs. VETERANS HEALTH ADMINISTRATION VHA was established in 1946 as a separate division within the Veterans Administration to meet the health care needs of U.S. Veterans (Veterans Administration, 2001b).
Veterans make up 10 percent of the nation’s population, but only a minority receive care through VHA (Kizer, 1999; Van Diepen, 2001a). Eligibility is triaged according to the available budget; those with compensable, service-connected disabilities are assigned the highest priority (Veterans Administration, 2001a). VHA serves as a payer of last resort for treatment not related to service-connected disabilities that is provided through VHA facilities.
Health care is delivered through 22 regional health care systems, referred to as Veterans Integrated Service Networks (VISNs). Each VISN contains 7 to 10 hospitals, 25 to 30 ambulatory care clinics, 4 to 7 nursing homes, and other care delivery units (Kizer, 1999).
Most clinical and administrative staff are employees of VHA. Generally, the VHA population is older, low-income, and characterized by high rates of chronic illness (see ). Approximately 19 percent of the total VHA population sought inpatient and outpatient mental health services (including those related to substance abuse) in 2000 (Van Diepen, 2001a). Spouses, and survivors. TRICARE for Life, a recent addition to the military health program, provides supplemental coverage (e.g., for prescription drugs) to the population aged 65 and over who enroll in Medicare Part B. TRICARE is administered by the Office of the Assistant Secretary of Defense (Health Affairs). At the core of the program is a direct care system of military treatment facilities (MTFs), which provide most of the care delivered to active-duty personnel and over half of that provided to TRICARE beneficiaries overall.
There is an MTF located at most major military facilities in the United States and abroad, each operated by one of the military services. TRICARE also has regional contracts with private-sector health plans to provide active-duty personnel with certain services not available through MTFs and to serve other beneficiaries. Non–active-duty beneficiaries may choose from among three program options: (1) TRICARE Prime, the lowest-cost plan, which assigns beneficiaries to a primary case manager, emphasizes preventive care, and makes use of MTFs whenever possible for specialty care; (2) TRICARE Extra, a preferred provider–type FFS discounted cost option; and (3) TRICARE Standard, the highest-cost plan, which provides maximal flexibility in selection of providers. TRICARE is intended to ensure “force health protection.” Active-duty personnel must be maintained at a level of health consistent with military demands according to a concept called “military readiness.” The TRICARE program must also be capable of providing urgent and emergency care to injured soldiers, sometimes stationed in remote areas.
Lastly, since the Gulf War, a great deal of attention has been focused on early detection of risks associated with the activities and settings of deployment (e.g., exposure to biological, chemical, and nuclear hazards and combat stress) and the ongoing monitoring of health consequences and effects of treatment (Institute of Medicine, 2000). The TRICARE beneficiary population tends to be young and healthy. In addition to force health protection, the service needs of other TRICARE beneficiaries, mostly active-duty dependents, are sometimes described as basically babies and bones (Jennings, 2001). With the implementation of TRICARE for Life, TRICARE’s elderly population can be expected to present health care needs similar to those of the Medicare population. Recognized American Indian and Alaska Native tribes. IHS currently provides health services to approximately 1.4 million American Indians and Alaska Natives belonging to more than 557 federally recognized tribes in 35 states.
The provision of these health services is based on treaties, judicial determinations, and acts of Congress that result in a unique government-to-government relationship between the tribes and the federal government. IHS, the principal health care provider, is organized as 12 area offices located throughout the United States. These 12 areas contain 550 health care delivery facilities operated by IHS and tribes, including: 49 hospitals; 214 health centers; and 280 health stations, satellite clinics, and Alaska village clinics. Almost 44 percent of the $2.6 billion IHS budget is transferred to the tribes to manage their own health care programs. Poverty and low education levels strongly affect the health status of the Indian people.
Approximately 26 percent of American Indians and Alaska Natives live below the poverty level, and more than one-third of Indians over age 25 who reside in reservation areas have not graduated from high school. Common inpatient diagnoses include diabetes, unintentional injuries, alcoholism, and substance abuse.
BROAD TRENDS AFFECTING THE NEEDS AND EXPECTATIONS OF BENEFICIARIES In identifying ways to improve the quality enhancement processes of government health care programs, it is important to understand both the needs and expectations of today’s beneficiaries and the trends likely to affect these needs and expectations in the future. As beneficiaries’ needs and expectations evolve over time, so, too, must the government health care programs.
This section highlights two important trends: the increase in chronic care needs and expectations for patient-centered care. Chronic Care Needs Trends in the epidemiology of health and disease and in medical science and technology have profound implications for health care delivery. Chronic conditions (defined as never resolved conditions, with continuing impairments that reduce the functioning of individuals) are now the leading cause of illness, disability, and death in the United States and affect almost half the U.S. Population (Hoffman et al., 1996). Most older people have at least one chronic condition, and many have more than one (Administration on Aging, 2001).
Fully 30 percent of those aged 65–74, and over 50 percent of those aged 75 and older report a limitation caused by a chronic condition (Administration on Aging, 2001). The proportion. Of children and adolescents with limitation of activity due to a chronic health condition more than tripled from 2 percent in 1960 to over 7 percent in the late 1990s (Newacheck and Halfon, 1998). Thus, the majority of U.S. Health care resources is now devoted to the treatment of chronic disease (Anderson and Knickman, 2001). This trend is strongly reflected in the government health care programs.
In the Medicare and VHA programs, most of the beneficiaries have multiple chronic conditions. Diseases such as asthma, diabetes, hypertension, cancer, congestive heart failure, and mental health and cognitive disorders are important clinical concerns for all or nearly all of the programs. The increasing prevalence of chronic illness challenges systems of care designed for episodic contact on an acute basis (Wagner et al., 1996). Hospitals and ambulatory settings are generally designed to provide acute care services, with limited communication among providers, and communication between providers and patients is often limited to periodic visits or hospitalizations for acute episodes. Serious chronic conditions, however, require ongoing and active medical management, with emphasis on secondary and tertiary prevention.
The same patient may receive care in multiple settings, so that there is frequently a need to coordinate services across a variety of venues, including home, outpatient office or clinic setting, hospital, skilled nursing facility, and when appropriate, hospice. There is mounting evidence that care for chronic conditions is seriously deficient. Fewer than half of U.S. Patients with hypertension, depression, diabetes, and asthma are receiving appropriate preventive, acute, and chronic disease management services (Clark, 2000; Joint National Committee on Prevention, 1997; Legorreta et al., 2000; Wagner et al., 2001; Young et al., 2001). Health care is typically delivered by a mix of providers having separate, unrelated management systems, information systems, payment structures, financial incentives, and quality oversight for each segment of care, with disincentives for proactive, continuous care interventions (Bringewatt, 2001).
For individuals with multiple chronic conditions, coordination of care and communication among providers are major problems that require immediate attention. There are many efforts under way to develop new models of care capable of meeting the needs of the chronically ill. For example, Healthy Future Partnership for Quality, an initiative in Maine now in its fifth year, enrolls insured individuals (from leading health plans and the state Medicaid program) and uninsured individuals (covered by a 10 percent surcharge on the fee for each insured participant and paid by insurance companies) with chronic illness in an intensive care management program that provides patient education, improved access to primary care and preventive services, and disease management (Healthy Futures Partnership. For Quality Project, 2002). The diabetes telemedicine collaborative in New York State (IDEATel, 2002) is a randomized controlled trial supported by CMS and others. It involves 1,500 patients, half of whom participate in home monitoring (using devices that read blood sugar, take pictures of skin and feet, and check blood pressure), intensive education on diabetes, and reminders and instructions on how to manage their disease.
The changing clinical needs of patients have important implications for government quality enhancement processes. These processes and the health care providers they monitor should be capable of assessing how well patients with chronic conditions are being managed across settings and time. This capability necessitates consolidation of all clinical and service use information for a patient across providers and sites, a most challenging task in a health care system that is highly decentralized and relies largely on paper medical records. Patient-Centered Care Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values and circumstances guide all clinical decisions (Institute of Medicine, 2001).
Informed patients participating actively in decisions about their own care appear to have better outcomes, lower costs, and higher functional status than those who take more passive roles (Gifford et al., 1998; Lorig et al., 1993, 1999; Stewert, 1995; Superio-Cabuslay et al., 1996; Van Korff et al., 1998). Most patients want to be involved in treatment decisions and to know about available alternatives (Guadagnoli and Ward, 1998); (Deber et al., 1996; Degner and Russell, 1988; Mazur and Hickam, 1997). Yet many physicians underestimate the extent to which patients want information about their care (Strull et al., 1984), and patients rarely receive adequate information for informed decision making (Braddock et al., 1999). Patient-centered care is not a new concept, rather one that has been shaping the clinician and patient relationship for several decades. Authoritarian models of care have gradually been replaced by approaches that encourage greater patient access to information and input into decision making (Emanuel and Emanuel, 1992), though only to the extent that the patient desires such a role. Some patients may choose to delegate decision making to clinicians, while patients with cognitive impairments may not be capable of participating in decision making and may be without a close family member to serve as a proxy.
Patients may also confront serious constraints in terms of covered benefits, copayments, and ability to pay (discussed below under benefits and copayments) The recently released physician charter by the American Board of Internal Medicine (ABIM) Foundation, the American College of Physicians. Principle of Patient Autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment.
Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demand for inappropriate care (American Board of Internal Medicine et al., 2002, p. The current focus on making the health care system more patient-centered stems at least in part from the growth in chronic care needs discussed above. Effective care of a person with a chronic condition is a collaborative process, involving extensive communication between the patient and the multidisciplinary team (Wagner et al., 2001).
Patients and their families or other lay caregivers deliver much if not most of the care. Patients must have the confidence and skills to manage their condition, and they must understand their care plan (e.g., drug regimens and test schedules) to ensure proper and safe implementation. For many chronic diseases, such as asthma, diabetes, obesity, heart disease, and arthritis, effective ongoing management involves changes in diet, increased exercise, stress reduction, smoking cessation, and other aspects of lifestyle (Fox and Gruman, 1999; Lorig et al., 1999; Von Korff et al., 1997). Pressures to make the care system more respectful of and responsive to the needs, preferences, and values of individual patients also stem from the increasing ethnic and cultural diversity that characterizes much of the United States. Although minority populations constitute less than 30 percent of the national population, in some states, such as California, they already constitute about 50 percent of the population (Institute for the Future, 2000). A culturally diverse population poses challenges that go beyond simple language competency and include the need to understand the effects of lifestyle and cultural differences on health status and health-related behaviors; the need to adapt treatment plans and modes of delivery to different lifestyles and familial patterns; the implications of a diverse genetic endowment among the population; and the prominence of nontraditional providers as well as family caregivers.
Although there has been a virtual explosion in Web-based health and health care information that might help patients and clinicians make more informed decisions, the information provided is of highly variable quality (Berland et al., 2001; Biermann et al., 1999; Landro, 2001). Some sites provide valid and reliable information. These include the National Library of Medicine’s Medline Plus sites (Lindberg and Humphreys, 1999); the National Diabetes Education Program, launched by the Centers for Disease Control and Prevention and the National Institutes of Health (U.S. Ernment Printing Office, 2001); and the National Health Council’s public education campaign.
There are also notable efforts to provide consumers with comparative quality information on providers and health plans. Examples are the health plan report cards produced by the National Committee for Quality Assurance and by the Consumers Union/California HealthCare Foundation Partnership and nursing home quality reports produced by CMS (Centers for Medicare and Medicaid Services, 2001a; Consumers Union/California Healthcare Foundation Partnership, 2002; National Committee for Quality Assurance, 2002). These efforts are discussed further in. There is little doubt, however, that we are embarking on a long journey to determine how best to make valid and reliable information available to diverse audiences with different cultural and linguistic capabilities (Foote and Etheredge, 2002).
In general, communication with consumers is enhanced through the use of common terminology, standardized performance measures, and reporting formats that follow common conventions. At the program level, the predilection of each government program to design and operate its health care quality enhancement processes independently is a serious problem. KEY PROGRAM FEATURES Although the focus of this report is on quality enhancement processes, the committee believes it important to acknowledge other important program features—such as benefits, payment approaches, and program design and administration—that influence quality. Just as the quality enhancement processes of the government programs are being assessed in this report, these other aspects of program design must be evaluated in the future for alignment with the objectives of those processes. Benefits and Copayments Health insurance was established in the United States in the 1930s and 1940s as a way to help the average person cope with the high costs of hospital care (Stevens, 1989). Today hospital care, although still very expensive, consumes about one-third of the health care dollar, and other facets of health care, such as prescription medications (9 percent with a growth rate of 13.8 percent) have grown in importance (Centers for Medicare and Medicaid Services, 2002c; Strunk et al., 2002).
Increased demand for these other facets of care reflects the growth in chronic care needs discussed earlier as well as new treatment options stemming from the extraordinary advances made in medical knowledge and technology, including minimally invasive surgery. Medicaid Arizona Medicaid Connecticut VHA TRICARE yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no yes yes no yes yes yes yes yes yes yes outpatient no yes yes yes yes yes yes some cases under hospice yes no yes no yes yes yes no yes yes yes no cThere is a good deal of variability across states in covered benefits. These three states were selected at random, and may or may not be representative of Medicaid plans in general. SOURCES: Agency for Health Care Administration, 2002; Anderson, 2002; Arizona Health Care Cost Containment System, 2002; Centers for Medicare and Medicaid Services, 2001b; and Connecticut Department of Social Services, 2002.
Tiple chronic conditions or that rewards prevention efforts such as extensive patient education for self-care. Other government programs offer important benefits in specific areas. VHA provides extensive mental health outpatient and inpatient services, especially for veterans with service-related disabilities. Medicaid provides residential care to the disabled and mentally retarded and long-term care for the elderly as a major part of program spending. Its benefit package is very comprehensive, including complex therapies for chronic conditions and congenital neurological disorders, such as cerebral palsy and Down syndrome, although states vary substantially in the scope of such benefits.
Both Medicaid and SCHIP programs cover outpatient prescription medications. Note that IHS is not included in because it is not an entitlement program or an insurance plan; therefore, it has no established benefit package (Indian Health Service, 2001). It is estimated. That funds appropriated to IHS by Congress cover approximately 60 percent of the health care needs of beneficiaries (Indian Health Service, 2001) Cost-sharing provisions are also important. Persons with chronic conditions are the heaviest users of health care services.
Deductibles and especially copayments can be sizable for these individuals. Some government health care programs, such as VHA, have minimal cost-sharing provisions, while others, especially Medicare, make more extensive use of such provisions. Also important is how the different programs interpret “medical necessity.” Even when a service is covered, payment for that service to a particular patient can be denied because of failure to meet a medical necessity criterion. In some instances, the quantity and duration of certain repetitive services may be limited unless the person shows functional improvement, not just stability or a slowing of decline (Anderson et al., 1998). The committee believes that each of the six government health care programs should review its benefit package and medical necessity criteria to identify enhancements in coverage or cost sharing that would facilitate the provision of more appropriate care to today’s beneficiaries. Such analyses should be conducted under alternative financial scenarios, including budget neutrality and varying levels of growth in expenditures. Efforts should also be made to understand how well the benefit packages of various government health care programs meet the needs of vulnerable populations and how well these packages fit together for those who are dual- or triple-eligible.
Payment Approaches Efforts to improve quality of care will be far more effective if implemented in an environment that encourages and rewards excellence. Unfortunately, current methods of payment to health plans and providers have the unintended consequence of working against quality objectives. This is true for both capitated and FFS payment methods.
Capitation is a payment arrangement in which health plans are paid a fixed amount for each enrollee under their care, regardless of the level of services needed by and actually provided to the person. Some health plans also pay physicians on a capitated basis for certain outpatient care, putting them at some degree of financial risk. Capitated payment rates are usually based on the average cost per enrollee of the enrolled group, often with adjustments for demographic characteristics (e.g., age and sex). Capitation rates are usually not adjusted for the health status of the enrolled population. Therefore, health plans and providers receive the same payment for someone who is less healthy and more likely to use a large number of services, such as a person with a. Chronic condition, as they do for someone who is healthier and likely to use no or fewer services during the year.
Health plans or clinicians that develop exemplary care programs for persons with chronic conditions may, as a result, attract a disproportionate share of these individuals. Under capitated payment systems, this situation has a highly negative financial impact on the health plan and providers (Luft, 1995; Maguire et al., 1998).
Persons with chronic conditions are more likely both to use services and to use a greater number of services during the year than those without chronic conditions. In 1996, for example, mean health care expenditures for a person with one or more chronic conditions were nearly 4 times the overall average ($3,546 versus $821) (Partnerships for Solutions, forthcoming). The average number of inpatient days per year is 0.2 for persons with no chronic conditions compared to 4.6 for those with five or more such conditions. Risk adjustment is a mechanism designed to ensure that payments to health plans and other capitated providers more accurately reflect the expected cost of providing health care services to the population enrolled.
Capitated plans and providers caring for a population that includes less healthy, higher-cost enrollees should receive higher payments. As more states require their entire Medicaid populations, including those who are disabled and have high health care needs, to enroll in managed care, adjustment of payments becomes even more necessary to ensure quality of care for enrollees (Maguire et al., 1998). Some states have addressed this issue. Michigan, for example, has created a separately funded capitated option for children with special health care needs (Department of Health and Human Services, 2000). Numerous options exist for risk-adjusting payments, but their application in government health care programs has been limited (Ellis et al., 1996; Hornbrook and Goodman, 1996; Newhouse et al., 1997; Starfield et al., 1991). The Medicare+Choice program has initiated demonstration projects to pilot the application of capitated payments adjusted for health status (Centers for Medicare and Medicaid Services, 2000d). Regardless of whether the beneficiary is enrolled in an indemnity or capitated plan, the physicians on the front line of care delivery in the private sector are generally compensated under FFS payment methods (Center for Studying Health System Change, 2001; Institute of Medicine, 2001).
FFS is the most common method of payment to physicians under Medicare, Medicaid, and SCHIP. Under FFS payment, physicians have strong financial incentives to increase their volume of billable services (e.g., visits and office-based procedures and tests). Sometimes the incentives of FFS or other physician payment methods are attenuated by incentives (e.g., bonuses) tied to performance (e.g., measures of safety, clinical quality, service), but this is not. In a 1998–1999 survey of a nationally representative sample of physicians, fewer than 30 percent indicated that their compensation was affected by performance-based incentives, a result similar to findings from a survey conducted in 1996–1997 (Stoddard et al., 2002). When they are used, performance-based incentives are more likely to be tied to patient satisfaction (24 percent) and quality measures (19 percent) than to measures that may restrain care, such as profiling (14 percent). The principal “reimbursable event” under FFS is a face-to-face encounter between a physician and patient, which may or may not trigger other reimbursable events, such as diagnostic tests and minor office procedures. Services such as e-mail communications, telephone consultations, patient education classes, and care coordination are important for the ongoing management of chronic conditions, but they are not reimbursable events.
Moreover, physicians who communicate with patients through e-mail or telephone to emphasize patient education, self-management of chronic conditions, and to coordinate care may experience a reduction in overall revenues if these uncompensated services have the effect of reducing patient demand for or time available to devote to reimbursable face-to-face encounters. There is no perfect payment method; all methods have advantages and disadvantages. FFS contributes to overuse of billable services (e.g., face-to-face encounters, ancillary tests, procedures) and underuse of preventive services, counseling, medications, and other services often not covered under indemnity insurance programs. Beyonce i am sasha fierce deluxe edition zip. Overuse, especially the provision of services that expose patients to more potential harm than good, is a serious quality-of-care and cost concern.
On the other hand, capitated payments may contribute to underuse—the failure to provide services from which patients would likely benefit. This is especially true when there is a good deal of turnover among plan enrollees so that the long-term cost consequences of underuse tend to be borne by another insurer.
Although particular payment methods may contain a bias towards underuse or overuse, it is important to note that the quality-of-care literature contains ample evidence of both phenomena occurring in both FFS and capitated payment systems, reinforcing the notion that payment is but one, albeit an important, factor influencing care (Chassin and Galvin, 1998). The committee believes enhancements can be made in both capitated and FFS payment approaches to encourage the provision of quality health care.
It should also be noted that there are some promising efforts under way to design alternative payment approaches and evaluate their impact on quality. The National Health Care Purchasing Institute, a nonprofit research institute supported by The Robert Wood Johnson Foundation, has identified various incentive models that might be effective in motivat.
Newspaper headlines from around the world about tests (13 April 1955) Public health is 'the science and art of preventing disease, prolonging life and promoting human through organized efforts and informed choices of society, organizations, public and private, communities and individuals.' Analyzing the health of a population and the threats is the basis for public health. The 'public' in question can be as small as a handful of people, an entire village or it can be as large as several continents, in the case of a. 'Health' takes into account physical, mental and social well-being. It is not merely the absence of disease or infirmity, according to the. Public health is., and are all relevant., and are other important subfields. Public health aims to improve the quality of life through prevention and treatment of, including mental health.
This is done through the of cases and, and through the promotion of healthy behaviors. Common public health initiatives include promoting and, delivery of, and distribution of to control the spread of. Modern public health practice requires of public health workers and professionals. Teams might include, or Depending on the need or, and even might be called on. Access to and public health initiatives are difficult challenges in. Public health infrastructures are still forming. Contents.
Background The focus of a public health intervention is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the, and. Many diseases are preventable through simple, nonmedical methods. For example, research has shown that the simple act of with soap can prevent the spread of many contagious diseases.
In other cases, treating a disease or controlling a can be vital to preventing its spread to others, either during an outbreak of or through or supplies., programs and distribution of are examples of common preventive public health measures. Measures such as these have contributed greatly to the health of populations and increases in life expectancy. Public health plays an important role in disease prevention efforts in both the developing world and in developed countries through local health systems and. The (WHO) is the international agency that coordinates and acts on issues. Most countries have their own government public health agencies, sometimes known as ministries of health, to respond to domestic health issues.
For example, in the, the front line of public health initiatives are state and local. The (PHS), led by the, and the, headquartered in, are involved with several international health activities, in addition to their national duties. In Canada, the is the national agency responsible for public health, emergency preparedness and response, and infectious and control and prevention. The is managed by the Ministry of Health & Family Welfare of the government of India with state-owned health care facilities. Current practice Public health programs. There's a push and pull, as you know, between cheap alternatives for industry and public health concerns.We're always looking at retrospectively what the data shows.Unfortunately, for example, take tobacco: It took 50, 60 years of research before policy catches up with what the science is showing— Laura Anderko, professor at Georgetown University and director of the Mid-Atlantic Center for Children's Health and the Environment commenting on public health practices in response to proposal to ban pesticide. Most governments recognize the importance of public health programs in reducing the incidence of disease, disability, and the effects of aging and other physical and mental health conditions, although public health generally receives significantly less government funding compared with medicine.
Public health programs providing have made strides in promoting health, including the eradication of, a disease that plagued humanity for thousands of years. Three former directors of the read the news that smallpox had been globally eradicated, 1980 The World Health Organization (WHO) identifies core functions of public programs including:. providing leadership on matters critical to health and engaging in partnerships where joint action is needed;. shaping a agenda and stimulating the generation, translation and of valuable knowledge;. setting norms and standards and promoting and monitoring their implementation;. articulating ethical and options;.
monitoring the health situation and assessing health trends. In particular, public health surveillance programs can:. serve as an for impending public health emergencies;.
document the impact of an intervention, or track progress towards specified goals; and. monitor and clarify the epidemiology of health problems, allow priorities to be set, and inform and strategies. diagnose, investigate, and monitor health problems and health hazards of the community Public health surveillance has led to the identification and prioritization of many public health issues facing the world today, including, and leading to the reemergence of infectious diseases such as. Antibiotic resistance, also known as drug resistance, was the theme of.
Although the prioritization of pressing public health issues is important, Laurie Garrett argues that there are following consequences. When foreign aid is funnelled into disease-specific programs, the importance of public health in general is disregarded. This public health problem of is thought to create a lack of funds to combat other existing diseases in a given country. For example, the WHO reports that at least 220 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is projected that the number of diabetes deaths will double by the year 2030. In a June 2010 editorial in the medical journal, the authors opined that 'The fact that, a largely preventable disorder, has reached epidemic proportion is a public health humiliation.' The risk of type 2 diabetes is closely linked with the growing problem of.
The WHO’s latest estimates as of June 2016 highlighted that globally approximately 1.9 billion adults were overweight in 2014, and 41 million children under the age of five were overweight in 2014. The United States is the leading country with 30.6% of its population being obese.
Mexico follows behind with 24.2% and the United Kingdom with 23%. Once considered a problem in high-income countries, it is now on the rise in low-income countries, especially in urban settings. Many public health programs are increasingly dedicating attention and resources to the issue of obesity, with objectives to address the underlying causes including and. Some programs and policies associated with public health promotion and prevention can be controversial. One such example is programs focusing on the prevention of transmission through campaigns and. Another is the control of.
Changing smoking behavior requires long-term strategies, unlike the fight against, which usually takes a shorter period for effects to be observed. Many nations have implemented to cut smoking, such as increased taxation and bans on smoking in some or all public places. Proponents argue by presenting evidence that smoking is one of the major killers, and that therefore governments have a duty to reduce the death rate, both through limiting and by providing fewer opportunities for people to smoke. Opponents say that this undermines individual freedom and personal responsibility, and worry that the state may be emboldened to remove more and more choice in the name of better population health overall. Simultaneously, while communicable diseases have historically ranged uppermost as a priority, and the underlying behavior-related risk factors have been at the bottom. This is changing, however, as illustrated by the hosting its first General Assembly Special Summit on the issue of non-communicable diseases in September 2011. Many health problems are due to maladaptive personal behaviors.
From an perspective, over consumption of novel substances that are harmful is due to the activation of an evolved for substances such as drugs, tobacco, alcohol, refined salt, fat, and carbohydrates. New technologies such as modern transportation also cause reduced physical activity. Research has found that behavior is more effectively changed by taking evolutionary motivations into consideration instead of only presenting information about health effects. Thus, the increased use of soap and hand-washing to prevent is much more effectively promoted if its lack of use is associated with the emotion of. Disgust is an evolved system for avoiding contact with substances that spread infectious diseases. Examples might include films that show how fecal matter contaminates food.
The marketing industry has long known the importance of associating products with high status and attractiveness to others. Conversely, it has been argued that emphasizing the harmful and undesirable effects of tobacco smoking on other persons and imposing smoking bans in public places have been particularly effective in reducing tobacco smoking. Emergency Response Team in after in 2008 There is a great disparity in access to and public health initiatives between and. In the developing world, public health infrastructures are still forming. There may not be enough trained or monetary resources to provide even a basic level of medical care and disease prevention. As a result, a large majority of disease and mortality in the developing world results from and contributes to extreme poverty. For example, many African governments spend less than 10 per person per year on health care, while, in the United States, the spent approximately US$4,500 per capita in 2000.
However, expenditures on health care should not be confused with spending on public health. Public health measures may not generally be considered 'health care' in the strictest sense.
For example, mandating the use of seat belts in cars can save countless lives and contribute to the health of a population, but typically money spent enforcing this rule would not count as money spent on health care. Large parts of the developing world remained plagued by largely preventable or treatable infectious diseases and poor and child health, exacerbated by and poverty. The reports that a lack of during the first six months of life contributes to over a million avoidable child deaths each year. Aimed at treating and preventing episodes among pregnant women and young children is one public health measure in countries.
Each day brings new front-page headlines about public health: emerging infectious diseases such as, rapidly making its way from China (see ) to Canada, the United States and other geographically distant countries; reducing through publicly funded health insurance programs; the and its spread from certain high-risk groups to the general population in many countries, such as in; the increase of and the concomitant increase in type II diabetes among children; the social, economic and health effects of; and the public health challenges related to such as the, in the United States and the. Since the 1980s, the growing field of has broadened the focus of public health from individual behaviors and to population-level issues such as, poverty, and education. Modern public health is often concerned with addressing determinants of health across a population. There is a recognition that our health is affected by many factors including where we live, genetics, our income, our educational status and our social relationships; these are known as '.' A social gradient in health runs through society. The poorest generally suffer the worst health, but even the middle classes will generally have worse health outcomes than those of a higher social stratum. The new public health advocates for population-based policies that improve health in an equitable manner.
Sustainable Development Goals. Further information: To address current and future challenges in addressing health issues in the world, the have developed the 2015 building off of the of 2000 to be completed by 2030. These goals in their entirety encompass the entire spectrum of development across nations, however Goals 1-6 directly address health disparities, primarily in developing countries.
These six goals address key issues in:, Hunger and, Health, Education, and women's empowerment, and water and. Public health officials can use these goals to set their own agenda and plan for smaller scale initiatives for their organizations. These goals hope to lessen the burden of disease and inequality faced by developing countries and lead to a healthier future. The links between the various sustainable development goals and public health are numerous and well established:. Living below the poverty line is attributed to poorer health outcomes and can be even worse for persons living in developing countries where is more common. A child born into poverty is twice as likely to die before the age of five compared to a child from a wealthier family.
The detrimental effects of hunger and that can arise from systemic challenges with food security are enormous. The estimates that 12.9 percent of the population in developing countries is undernourished. Health challenges in the developing world are enormous, with 'only half of the women in developing nations receiving the recommended amount of healthcare they need. has yet to be reached in the world. Public health efforts are impeded by this, as a lack of education can lead to poorer health outcomes. This is shown by children of mothers who have no education having a lower survival rate compared to children born to mothers with primary or greater levels of education.
Cultural differences in the role of women vary by country, many gender inequalities are found in developing nations. Combating these inequalities has shown to also lead to better public health outcome. In studies done by the on populations in developing countries, it was found that when women had more control over household resources, the children benefit through better access to food, healthcare, and education. Basic resources and access to clean sources of water are a basic.
However, 1.8 billion people globally use a source of drinking water that is fecally contaminated, and 2.4 billion people lack access to basic sanitation facilities like. A lack of these resources is what causes approximately 1000 children a day to die from that could have been prevented from better water and infrastructure. Education and training Education and training of public health professionals is available throughout the world in Schools of Public Health, Medical Schools, Veterinary Schools, Schools of Nursing, and Schools of Public Affairs.
The training typically requires a with a focus on core disciplines of, and. In the global context, the field of public health education has evolved enormously in recent decades, supported by institutions such as the and the, among others. Operational structures are formulated by strategic principles, with educational and career pathways guided by competency frameworks, all requiring modulation according to local, national and global realities. It is critically important for the health of populations that nations assess their public health human resource needs and develop their ability to deliver this capacity, and not depend on other countries to supply it. Schools of public health: a US perspective In the, the Welch-Rose Report of 1915 has been viewed as the basis for the critical movement in the history of the institutional schism between public health and medicine because it led to the establishment of schools of public health supported by the.
The report was authored by, founding dean of the, and of the Rockefeller Foundation. The report focused more on research than practical education. Some have blamed the Rockefeller Foundation's 1916 decision to support the establishment of schools of public health for creating the schism between public health and medicine and legitimizing the rift between medicine's laboratory investigation of the mechanisms of disease and public health's nonclinical concern with environmental and social influences on health and wellness. Even though schools of public health had already been established in, and, the United States had still maintained the traditional system of housing faculties of public health within their medical institutions.
A $25,000 donation from businessman instituted the in 1912 conferring its first doctor of public health degree in 1914. The became an independent, degree-granting institution for research and training in public health, and the largest public health training facility in the United States, when it was founded in 1916. By 1922, schools of public health were established at, and on the Hopkins model. By 1999 there were twenty nine schools of public health in the US, enrolling around fifteen thousand students. Over the years, the types of students and training provided have also changed. In the beginning, students who enrolled in public health schools typically had already obtained a medical degree; public health school training was largely a second degree for.
However, in 1978, 69% of American students enrolled in public health schools had only a. Degrees in public health. Main article: Schools of public health offer a variety of degrees which generally fall into two categories: professional or academic. The two major postgraduate degrees are the (MPH) or the in Public Health (MSPH). Doctoral studies in this field include (DrPH) and (PhD) in a subspeciality of greater Public Health disciplines. DrPH is regarded as a professional degree and PhD as more of an academic degree. Professional degrees are oriented towards practice in public health settings.
The, (DHSc) and the are examples of degrees which are geared towards people who want careers as practitioners of public health in health departments, managed care and community-based organizations, hospitals and consulting firms, among others. Degrees broadly fall into two categories, those that put more emphasis on an understanding of epidemiology and statistics as the scientific basis of public health practice and those that include a more eclectic range of methodologies. A Master of Science of Public Health is similar to an MPH but is considered an academic degree (as opposed to a professional degree) and places more emphasis on scientific methods and research. The same distinction can be made between the DrPH and the DHSc. The DrPH is considered a professional degree and the DHSc is an academic degree.
Examples Of Innovative Public Health Programs
Academic degrees are more oriented towards those with interests in the scientific basis of public health and who wish to pursue careers in research, university teaching in graduate programs, policy analysis and development, and other high-level public health positions. Examples of academic degrees are the, (ScD), and (DHSc). The doctoral programs are distinct from the MPH and other professional programs by the addition of advanced coursework and the nature and scope of a research project. In the United States, the Association of Schools of Public Health represents (CEPH) accredited schools of public health. Is the for graduate studies in public health.
The society was founded in 1924 at the. Currently, there are approximately 68 chapters throughout the United States and Puerto Rico. History Early history. 1802 caricature of vaccinating patients who feared it would make them sprout cowlike appendages. The practice of became prevalent in the 1800s, following the pioneering work of in treating. 's discovery of the causes of amongst sailors and its mitigation via the introduction of on lengthy voyages was published in 1754 and led to the adoption of this idea by the.
Grisham security door installation. Efforts were also made to promulgate health matters to the broader public; in 1752 the British physician Sir published Observations on the Diseases of the Army in Camp and Garrison, in which he advocated for the importance of adequate ventilation in the and the provision of for the soldiers. With the onset of the, living standards amongst the working population began to worsen, with cramped and unsanitary urban conditions. In the first four decades of the 19th century alone, 's population doubled and even greater growth rates were recorded in the new industrial towns, such as and.
This rapid exacerbated the spread of disease in the large that built up around the and. These settlements were cramped and primitive with no organized. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants. Unavailable housing led to the rapid growth of and the began to rise alarmingly, almost doubling in and.
Warned of the dangers of overpopulation in 1798. His ideas, as well as those of, became very influential in government circles in the early years of the 19th century. Public health legislation. Sir was a pivotal influence on the early public health campaign. The first attempts at sanitary reform and the establishment of public health institutions were made in the 1840s., physician at the, began to write papers on the importance of public health, and was one of the first physicians brought in to give evidence before the in the 1830s, along with and. Smith advised the government on the importance of and sanitary improvement for limiting the spread of infectious diseases such as and.
The reported in 1838 that 'the expenditures necessary to the adoption and maintenance of measures of prevention would ultimately amount to less than the cost of the disease now constantly engendered'. It recommended the implementation of large scale government projects to alleviate the conditions that allowed for the propagation of disease. The was formed in on 11 December 1844, and vigorously campaigned for the development of public health in the.
Its formation followed the 1843 establishment of the Health of Towns Commission, chaired by Sir, which produced a series of reports on poor and insanitary conditions in British cities. These national and local movements led to the, finally passed in 1848. It aimed to improve the sanitary condition of towns and populous places in England and Wales by placing the supply of water, sewerage, drainage, cleansing and paving under a single local body with the General Board of Health as a central authority. The Act was passed by the of, in response to the urging of. Chadwick's seminal report on The Sanitary Condition of the Labouring Population was published in 1842 and was followed up with a supplementary report a year later. For various diseases was made compulsory in the in 1851, and by 1871 legislation required a comprehensive system of registration run by appointed vaccination officers. Further interventions were made by a series of subsequent, notably the.
Reforms included latrinization, the building of, the regular followed by or disposal in a, the and the draining of standing water to prevent the breeding of mosquitoes. The mandated the reporting of infectious diseases to the local sanitary authority, which could then pursue measures such as the removal of the patient to hospital and the disinfection of homes and properties. In the United States, the first public health organization based on a state health department and local boards of health was founded in in 1866. Epidemiology. 's dot map, showing the of cholera cases in the London epidemic of 1854.
The science of was founded by 's identification of a polluted public water well as the source of an 1854 outbreak in London. Snow believed in the of disease as opposed to the prevailing. He first publicized his theory in an essay, On the Mode of Communication of Cholera, in 1849, followed by a more detailed treatise in 1855 incorporating the results of his investigation of the role of the water supply in the epidemic of 1854. By talking to local residents (with the help of ), he identified the source of the outbreak as the public water pump on Broad Street (now ).
Although Snow's chemical and microscope examination of a water sample from the did not conclusively prove its danger, his studies of the pattern of the disease were convincing enough to persuade the local council to disable the well pump by removing its handle. Snow later used a to illustrate the cluster of cholera cases around the pump. He also used statistics to illustrate the connection between the quality of the water source and cholera cases. He showed that the was taking water from sewage-polluted sections of the and delivering the water to homes, leading to an increased incidence of cholera.
Snow's study was a major event in the history of public health and geography. It is regarded as the founding event of the science of. Disease control. Injecting a plague vaccine in Karachi, 1898. With the pioneering work in of French chemist and German scientist, methods for isolating the responsible for a given disease and vaccines for remedy were developed at the turn of the 20th century. British physician identified the as the carrier of and laid the foundations for combating the disease.
Revolutionized by the introduction of to eliminate. French epidemiologist proved that was carried by on the back of, and Cuban scientist and U.S. Americans and demonstrated that mosquitoes carry the virus responsible for. Brazilian scientist identified a and its vector. With onset of the and as the prevalence of, public health began to put more focus on such as and.
Previous efforts in many developed countries had already led to dramatic reductions in the using preventative methods. In Britain, the infant mortality rate fell from over 15% in 1870 to 7% by 1930. Country examples France followed well behind Bismarckian Germany, as well as Great Britain, in developing the welfare state including public health. Tuberculosis was the most dreaded disease of the day, especially striking young people in their 20s. Germany set up vigorous measures of public hygiene and public sanatoria, but France let private physicians handle the problem, which left it with a much higher death rate. The French medical profession jealously guarded its prerogatives, and public health activists were not as well organized or as influential as in Germany, Britain or the United States. For example, there was a long battle over a public health law which began in the 1880s as a campaign to reorganize the nation's health services, to require the registration of infectious diseases, to mandate quarantines, and to improve the deficient health and housing legislation of 1850.
However the reformers met opposition from bureaucrats, politicians, and physicians. Because it was so threatening to so many interests, the proposal was debated and postponed for 20 years before becoming law in 1902. Success finally came when the government realized that contagious diseases had a national security impact in weakening military recruits, and keeping the population growth rate well below Germany's.
United States. See also: Modern public health began developing in the 19th century, as a response to advances in science that led to the understanding of, the source and spread of disease.
As the knowledge of contagious diseases increased, means to control them and prevent infection were soon developed. Once it became understood that these strategies would require community-wide participation, disease control began being viewed as a public responsibility. Various organizations and agencies were then created to implement these disease preventing strategies. Most of the Public health activity in the United States took place at the municipal level before the mid-20th century. There was some activity at the national and state level as well.
In the administration of the second president of the United States, the Congress authorized the creation of hospitals for mariners. Expanded, the scope of the governmental health agency expanded. In the United States, public health worker, M.D. Established many programs to help the poor in New York City keep their infants healthy, leading teams of nurses into the crowded neighborhoods of and teaching mothers how to dress, feed, and bathe their babies. Another key pioneer of public health in the U.S. Was, who founded the house in New York. The was a significant organization for bringing health care to the urban poor.
Dramatic increases in average life span in the late 19th century and 20th century, is widely credited to public health achievements, such as programs and control of many infectious diseases including, and; effective health and safety policies such as and; improved; measures; and programs designed to decrease by acting on known risk factors such as a person's background, lifestyle and environment. Another major public health improvement was the decline in the 'urban penalty' brought about by improvements in. These improvements included of drinking water, filtration and which led to the decline in deaths caused by infectious such as and intestinal diseases. The federal Office of Indian Affairs (OIA) operated a large-scale field nursing program.
Field nurses targeted native women for health education, emphasizing personal hygiene and infant care and nutrition. Logo for the, a governmental agency dealing with public health. Public health issues were important for the during the colonial era. Epidemic disease was the main factor in the decline of indigenous populations in the era immediately following the sixteenth-century conquest era and was a problem during the colonial era. The Spanish crown took steps in eighteenth-century Mexico to bring in regulations to make populations healthier. In the late nineteenth century, Mexico was in the process of modernization, and public health issues were again tackled from a scientific point of view.
Even during the (1910–20), public health was an important concern, with a text on hygiene published in 1916. During the Mexican Revolution, feminist and trained nurse founded the, treating wounded soldiers no matter for what faction they fought. In the post-revolutionary period after 1920, improved public health was a revolutionary goal of the Mexican government.
The Mexican state promoted the health of the Mexican population, with most resources going to cities. Concern about disease conditions and social impediments to the improvement of Mexicans' health were important in the formation of the. The movement flourished from the 1920s to the 1940s. Mexico was not alone in Latin America or the world in promoting. Government campaigns against disease and alcoholism were also seen as promoting public health.
The was established in 1943, during the administration of President to deal with public health, pensions, and social security. See also: Since the 1959 the has devoted extensive resources to the improvement of for its entire population via universal access to health care. Infant mortality has plummeted. As a policy has seen the Cuban government sent doctors as a form of aid and export to countries in need in Latin America, especially, as well as Oceania and Africa countries. Colombia and Bolivia Public health was important elsewhere in Latin America in consolidating state power and integrating marginalized populations into the nation-state. In Colombia, public health was a means for creating and implementing ideas of citizenship. In Bolivia, a similar push came after their 1952 revolution.
See also. Berridge, Virginia. Public Health: A Very Short Introduction (Oxford University Press, 2016). Berridge, Virginia, et al.
Public Health in History (2011). Breslow, Lester, ed. Betrayal of Trust: the Collapse of Global Public Health. New York: Hyperion.
Heymann, David L., ed. Washington, D.C.:. Heggenhougen, Kris; Stella R Quah, eds. International Encyclopedia of Public Health. Amsterdam Boston: Elsevier/Academic Press. Jalil, Hanni. 'Curing a Sick Nation: Public Health and Citizenship in Colombia, 1930-1940.'
PhD dissertation, University of California, Santa Barbara, 2015. La Berge, Ann F. Mission and Method: The Early Nineteenth-Century French Public Health Movement.
New York: Cambridge University Press 1992. Novick, Lloyd F; Cynthia B Morrow; Glen P Mays (2008). Public Health Administration: Principles for Population-Based Management (2nd ed.).
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Sudbury, MA: Jones and Bartlett Pub. Pacino, Nicole. 'Prescription for a Nation: Public Health in Post-Revolutionary Bolivia, 1952-1964.' PhD dissertation, University of California, Santa Barbara 2013.
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Schneider, Dona; David E Lilienfeld (2008). Public Health: the Development of a Discipline. New Brunswick, NJ: Rutgers University Press. Rosen, George. A History of Public Health.
New York: MD Publications 1958. and Claudia Agostoni, 'Science and Public Health in the Century of Revolution,' in A Companion to Mexican History and Culture, William H. Blackwell Publishing 2011, pp. 561–574. Stokols, D.; Hall, K.L.; Vogel, A.L.
'Transdisciplinary public health: Core characteristics, definitions, and strategies for success'. In Haire-Joshu, D.; McBride, T.D. San Francisco: Jossey-Bass. Globalization, the Human Condition, and Sustainable Development in the Twenty-first Century: Cross-national Perspectives and European Implications. With Almas Heshmati and a Foreword by Ulrich Brand (1st ed.). Anthem Press, London.
Turnock, Bernard (2009). Public Health: What It Is and How It Works (4th ed.). Sudbury, MA: Jones and Bartlett Publishers. Oxford Textbook of Public Health (5th ed.). Oxford and New York: Oxford University Press. White, Franklin; Stallones, Lorann; Last, John M.
Oxford University Press. External links Wikimedia Commons has media related to. Wikiversity has learning resources about.
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